Category Archives: Yang

The Caregiver Shortage and Immigration

In reaction to the Trump administration’s recent immigration ban, Lori Porter, founder and CEO of the National Association of Health Care Assistants, pointed out a connection between the immigration issue and LTC staffing levels. In a recent Facebook post, she stated:

“A large percentage of CNAs are from the banned countries. Long Term Care is always testifying before congress for immigration to solve their staffing issue… I know nursing homes in this country who are largely staffed by those affected. Did anyone stop to think about who would care for the residents? Especially in a country who will not come out in sufficient numbers to take care of their own OLD citizens! … I have heard from nursing homes all day who will not have enough CNAs to staff their building because so many CNAs have left out of fear.”

In support of Lori Porter’s assessment, we do know two facts:  that over 50 percent of CNAs leave their jobs every year (PHI Factsheet) and over 20 percent of caregivers in the U.S. were not born in this country (Market Watch).

My concerned is about the vulnerability of caregivers coming into this country on work visas, especially if their legal status is tied to their employment. Since advocating for our elders is such a big part of what we do as caregivers, we need workers who feel secure enough to speak out within the facility and, when appropriate, in the public forum. Sometimes, we are the last line of defense for our residents and if we do not speak, no one will. Too often, incidents and issues that should be dealt with in the open are swept under the rug, mainly out of fear of some form of retaliation.

If Long Term Care is to rely on immigration to solve the caregiver shortage in this country, what kind of protections can we provide these workers so that they feel secure enough to speak out and advocate for our elders when necessary?

 

For Veterans Day

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Yang

The only time I ever saw my father cry was on Christmas Eve, 1993. On that night, my wife and I invited my parents to go with us to a candlelight service at our church. Toward the end, we lit our candles and sang the final song of the service.  About half way through, I could see the flame on my father’s candle flicker and wave in his trembling hand. His voice cracked as he raised a sleeve to his face to wipe away a tear and he was unable to finish singing. The song was Silent Night. While his reaction was out of character, I had a pretty good idea of what was behind it.

My father was a WWII vet and served with the U.S. Army Air Corp in the Pacific Theatre. He participated in campaigns in New Guinea, the Philippines and Okinawa before joining the occupation forces after Japan surrendered in September, 1945. As typical of males of his generation, he was somewhat “hard boiled,” tough and not given to displays of sloppy sentimentalism.  Yet, he was affable and charming, and used his gentle sense of humor to make connections with people of all kinds. He was a natural salesman and had a knack of making instant friends with strangers. He loved kids and animals, but had little tolerance for pretentiousness and superficiality in adults.

For over 35 years, I observed this same kind of tough/gentle combination in the personalities of many of the residents at the veteran’s home where I worked as a caregiver. I think there is something about serving your country in wartime that sharpens your appreciation for what really counts in life. It’s difficult for those of us who did not serve to fully comprehend this perspective.

For many of the vets I cared for, the Second World War was the seminal event of their lives and helped define who they became as people. The average age of the U.S. soldier in WWII was 26, the draft age 18. At an age that these young men should have been starting work and families, or going off to college, they instead found themselves far away from home in harsh, lonely, and dangerous places. Unlike the other major combatants in WWII, the U.S. did not rotate troops. If you served overseas in WWII, you stayed overseas for the duration of the war. It’s not hard to believe that extended periods in this kind of environment must have profoundly shaped the lives of these young men in ways that heavily influenced their later life experience. And the wounds they suffered were not always visible.

My father enlisted in December of 1942 at age 19. He was sent to the Pacific in August, 1943 and did not return home until November of 1945. I grew up hearing stories about his time overseas. There were stories of the GI’s relationship with the local natives, the oppressive heat and humidity of the New Guinea jungle, the bugs, the snakes, the dysentery, waiting days on end aboard “that damn LST” before landing on the island of Luzon in the Philippines, of watching P-38’s dogfight with Zeros over Port Moresby, and of befriending Japanese children during his time at Tachikawa Airbase after the surrender. The kids were always the first to come out of hiding.

One story stood out above the rest. It happened on Christmas Eve, 1943. He was on New Guinea where the jungle made a cohesive front line difficult to define. He didn’t know if he would ever see home again, was unsure that he even had a future, and scared.

On that night, he and two of his buddies were assigned to deliver some kind of equipment (I don’t recall exactly what) to a location about an hour and a half walk from their camp. As they crept down the dark jungle path, they would halt every so often and listen for any indications of activity – friendly or otherwise – around them. About three-quarters of an hour into the trip, my father turned around and raised his hands, signaling to his companions to stop.

“Did you hear that?” he whispered.

They hadn’t heard anything. The three men listened in silence for a few moments, but heard nothing more, and they proceeded down the trail.

A short distance later, my father stopped again.

“You must have heard that. It sounds like something clinking.”

This time, all three men heard it. But there was something about this mysterious sound in the jungle that made them more curious than cautious. As they walked on, they began to discern musical notes. Someone was playing some kind of instrument out here in No Man’s Land.

Soon, they saw lights ahead. As they came to a clearing, my father and his buddies beheld a surreal scene, a sight that would be burned into his memory for the rest of his life: there, in the middle of the New Guinea jungle, was the Salvation Army handing out cookies and coffee to homesick soldiers.

My father simply couldn’t believe what he was seeing. But his astonishment soon gave way to a different kind of feeling. This was a tangible taste of home, something marvelously normal in this alien land. The idea that these people would volunteer to come out on this night and subject themselves to the extreme discomfort and very real dangers of this place just to bring him and his comrades a bit of home on Christmas Eve filled him with a feeling that transcended mere gratitude.  

I don’t know if my father ever told us what instruments they were playing. But he never left any doubt what song he and buddies heard as they entered the clearing. It was Silent Night.   

I’m pretty sure that there were other things about his experience in the war that my father felt just as deeply, but that he never shared with us. I did know that, as happens frequently with soldiers in war zones, he developed a very close bond with some of his buddies. And I knew that some of them didn’t make it home.

My father sacrificed his youth to serve his country. And he left a part of himself over there. Later in life, he became active in the DAV and other veterans groups. After his faith and his family, his participation and service in these organizations was the most important thing in his life.

When we take the time to recognize and thank our veterans for their sacrifice and service, it really does mean something.

 

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The Savvy Resident’s Guide

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Yang

Empathy is at the heart of caregiving. While the ability to understand and share the feelings of others has an intuitive element, a natural byproduct of genuine compassion, this awareness can be developed and enhanced through thought and imagination. Simply put, we can use what we know about another person to put ourselves in their shoes.

As I read through Dr. Eleanor Feldman Barbera’s nursing home primer, The Savvy Resident’s Guide, I found myself doing exactly that: imagining what it would be like to be an elder about to enter a nursing home. The book, subtitled Everything You Want to Know About Your Nursing Home Stay, But Were Afraid to Ask touches on all the basic topics, including what to expect when you first arrive, working with staff, managing medications, your relationship with medical and social work staff, dietary issues, rehab, activities, money issues and lodging complaints.

Throughout the book, “Dr. El” offers practical advice on everything from the best way to request assistance from care staff to techniques that help you stay motivated during rehab sessions to the best way to talk to your doctor. Dr. El keeps the tone light, often illustrating her points with personal interactions from her own experience. A common theme running through each chapter is that as a resident you are not powerless and that, in fact, there is a great deal that you can do to improve the quality of your experience in a nursing home. The book is an easy read, literally an easy read, with its large print format.

There is very little in The Savvy Resident’s Guide that could be considered new information for experienced caregivers. But in a way, for us at least, that’s the point. These issues are so woven into the fabric of our work experience that they become second nature to us and sometimes we lose sight of the fact that what might be obvious to us might not be as clear to someone else. A guide such as this, geared for new residents and their families, can help us become more aware of the basic kinds of information new residents need to help them cope with what can often be an overwhelming psychological adjustment.

In another way, as Dr. El invites us to in the foreword, the book helps us step into the new resident’s shoes because it reminds us of when we as caregivers were new to the system. The whirl of faces and personalities, the jargon, the strange cultural norms and customs of the facility and care unit, were all things we had to adjust to. Now, with a little imagination, we can put ourselves in the place someone who might not be feeling well to start, who perhaps has gone through a sustain period of loss and now has to adjust to this strange new world. Our empathy can begin even before the resident enters the front door.

Dr. Eleanor Feldman Barbera is an accomplished speaker and consultant with 20 years’ experience as psychologist in long-term care. Her blog, My Better Nursing Home can be read here. Dr. El is also a regular contributor to McKnight’s LTC News. The Savvy Resident’s Guide is available on Amazon as a paperback or as Kindle book here.

There’s Nothing Like a Good Dog

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Yang

As I begin the HS care routine, my thoughts wander to home, to Jenny and the girls. I always get a little tug of homesickness around this time in the shift. The girls are picking out their bedtime stories right now, each gets to choose one book and they pick one together.  They’ll gather around the bed of our youngest – along with our little Australian Shepard, Kip – and Jenny will read to them. Then, she’ll tuck them in, kiss them good night, and they’ll drift away with Wynken, Blynken and Nod. Not being there is the hardest part of being here.

Tonight, it’s worse than usual because I’ve been pulled to a unit that I’m not familiar with and I’m the outsider. I don’t know the staff well and I know nothing about the residents in my group, save for the information on my “cheat sheet” and what the other caregivers have time to tell me. For the rest I have to depend on what I can glean from the residents themselves.

Ziggy can’t help me much in that regard. He has a pleasant demeanor and he follows simple cues, but he doesn’t respond to all of my questions and when he does respond it’s with a nod or one word answer.  And he seems reluctant to maintain eye contact.

In the dietary column, the cheat sheet states that Ziggy is a “feeder,” an uncomfortably crude way of saying that he can’t eat without total assistance. But the information is accurate, as I discovered at supper time. He loves to eat – that isn’t on the cheat sheet – I couldn’t get his dinner on the spoon fast enough for him. He polished off his tray in ten minutes and accepted a second dessert when one of the regular caregivers offered. For caregivers, there is something satisfying about a resident who likes to eat. And I could tell from the regular caregivers’ interaction with him that he is just about everybody’s favorite. That isn’t on the cheat sheet either.

There is a lot about Ziggy that isn’t on the cheat sheet. You can’t tell a story in box.

He nods as I explain that I’m going to help him on to his bed, but he says nothing. Under the “transfer” column of the cheat sheet, he is listed as 1HH, meaning one human help. He is as tall as I am and not thin, but if the sheet is up to date, he should be able to bear weight and I should be able to get him into his bed without having to ask the other caregivers for help.

I position his Geri chair parallel to his bed, about midway between the head and foot. This leaves room for me to help him stand and pivot 90 degrees, then ease him into a sitting position on the edge of the bed. The next step is to use the edge of the bed as a fulcrum and help him swing his legs into the bed, effectively creating another 90 degree pivot. If all goes to plan, his head will end up straight on the pillow.

I pause after getting him on the bed. I always like to take a moment when a resident is sitting on the edge of bed, whether it’s in the process of getting out or going in.  Just to let him get his bearings after the change of position. Sometimes I’ll sit on the bed with him – for just a moment or two – steadying him if necessary.  

As I’m sitting next to Ziggy, my attention is drawn to two photos tacked to his personal poster board hanging on the wall over his night stand. Other than the Activity Department’s weekly newsletter, the photos are the only items on the board.  In most of the residents’ rooms these poster boards are covered with various personal items such as photos, greeting cards, notes, and assorted decorations. For our residents, these items sometimes serve as tangible, but slender connections to the lives they had before they came here. For us, they provide tiny shreds of evidence of who they are as people.

One of the pictures is an 8×10 of a gorgeous pure bred German Shepard standing in someone’s front yard. A smaller photo shows a much younger Ziggy kneeling next to the Shepard with his him arm draped across the dog’s back. Both photos are faded, dog-eared, and peppered with a dozen thumb-tack holes along the top edges.

From my spot on the bed, the larger photo is within arm’s reach. I lean over, remove it from the board, and hold it up in front of Ziggy.

“He’s beautiful, Ziggy.”

Ziggy reaches for the photo and I hand it to him. He studies it and nods. “Chummy is a good dog.”

Okay, present tense then. I’ll follow his lead and we’ll stay there. “Yes, he looks like a great dog.”

He nods again. “Chummy is a good, good dog.”

“Are you best buddies?”

“Yeah. He’s my dog.”

He still hasn’t taken his eyes off the photo.

 “Do you play with him?”

“Yes… he plays.”

 “There’s nothing like a good dog. I have one too.”

He looks at me, eyebrows slightly raised.

“Here, I’ll show you a picture of her.” I lean back and retrieve my wallet from my front pants pocket. I slip a small photo of Kip from its protective plastic sleeve. The picture shows Kip with all four legs off the ground, snatching a tennis ball in mid-air.

Ziggy is impressed. “He’s a good dog!”

“Yes, she is,” I agree, but I stand firm on the gender. “She loves to play fetch. We play until I get too tired to throw the ball. I always get tired way before she does.”

Ziggy chuckles, he’s familiar with that story.  I hand the photo to Ziggy. He’s still holding the picture of Chummy in his other hand and looks from one photo to the other, apparently comparing the two dogs.

“Ziggy, do you suppose Chummy is more expensive to feed than Kip?”

He grins, “Oh yes, Chummy eats a lot.”

“Kip loves to hunt.  One time she ran away and came home with the leg of a deer. And rabbits don’t dare to come in our yard anymore. Does Chummy hunt too?”

“Oh, no, no. Chummy doesn’t hunt.” He hands me Kip’s picture and returns his gaze to his Shepard. “Chummy is a good dog.”

“Do want to hear a secret about Kip, Ziggy?”

He looks back at me. “Yes… what is it?”

“My wife let’s her sleep in our bed.”

Ziggy shakes his head. “Chummy sleeps in his own bed.”

“I know, we’re not supposed to let her on our bed. But we do anyway.” I put my hand on his shoulder and say, “At least there is one thing that we both know…”

He looks at me again, “What?”

“… There’s nothing like a good dog.”

He smiles and nods. “Yes, Chummy is a good, good dog.”

I proceed with his HS care and wonder if Ziggy will dream about Chummy tonight. I hope so.

I also wonder what other connections we could make if I had more time and knew more about who Ziggy is.

A Matter of Death and Life

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Yang

The subject of death comes up often in this line of work. On this blog, Alice and May have visited it on more than one occasion. They have shared how they experienced losing residents they’ve known and cared for, and how they cope with the deep sense of personal loss. These experiences and feelings are echoed every single day in the hallways of LTC facilities and on social media. Death and loss are realities that all caregivers have to deal with at some point. For some, it becomes too much to bear and they leave the field.

Death is also at the heart of the negative public perception of nursing homes. The term itself, nursing home, evokes images of forsaken and forgotten souls, a place where we “stick” people when they are no longer of any use and we don’t want to be bothered with what’s left of them. That even facilities that offer good care and where the residents seem content, are still essentially gilded human warehouses, nice places to go and wait for the inevitable. Abandon hope all ye who enter here.

Those of us who work in direct care know that the reality is not quite that dreary. While we can be the staunchest critics of the nursing home industry – because of what we know about the very real problems – we also know that these places are and can be so much more than just human warehouses. We know that not everyone who enters them is prepared to simply submit and waste away. That sometimes people who have experienced severe neglect on the outside can actually rally after admission. Good medical care, proper diet, therapy, and a sense of community and belonging, can go a long way in restoring a sense of wellbeing and hope. That yes, even here, life goes on.

While good care is essential, it does not address the deeper question of a meaningful existence. Here, in the final stages of life, where comfort is often regarded as the highest value and the will to live runs on sheer momentum, the question arises – and I’m going to be blunt – why bother? Why bother to go on when you no longer feel productive or useful? Why bother when you feel as though you’ve become nothing but a burden? Why bother when you’ve lost so much that you hold so dear? And the toughest question of all: why bother when the end result is going to be the same no matter what you do?

Good caregivers do all they can to address the “why bothers?” Through our awareness of our elders as individuals and by engaging them emotionally, we assure them that if nothing else, they still matter because they matter to us. We can’t give them back everything and we can’t reach everyone, but there are opportunities to make a real difference and we morally obligated to make the most of them.  

Still, there is that nagging reality always present in background, the sense of doom and meaninglessness associated with our mortality.

But we are not powerless. First, we have to reject the conventional view of aging: that the final stage of life is less meaningful than everything that comes before it. We need to embrace the idea that we can change, grow and develop right up to the end. And we must stop downgrading the intrinsic value of moments that are experienced during this stage of life. Even to the end, we can retain our capacity to be surprised or fascinated or enthralled, and to value the comic absurdity of life. And we can still lose ourselves in these moments and share them with those around us without reference to some ultimate meaning.

Second, we have to rebel against death itself. Not against its reality, but against its hold on us; against the idea that our fate to die must inform our actions and constrain how we experience life. We need not be held captive to the ego’s revulsion to nonexistence. By liberating ourselves from death’s grip on our being, we are giving ourselves permission to really live.

For our elders, it’s not enough that we tell them that life is still worth living.  Instead, as caregivers we must discover what that means to them, in the most specific, practical terms. We must facilitate and share with them, when we can, those things they find meaningful. Each time we do this, we are joining them in their rebellion against death and boldly answer the question “why bother?” And we celebrate with them one more victory in life.

Heroes and Role Models

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Yang

When I was 9 years old, my heroes were Detroit Tiger greats Al Kaline and Willie Horton. Like just about every other kid in the neighborhood, I rooted and watched in adoration, wishing someday to be like them. I mimicked their behavior on the field, giving special attention to what they did while at bat. 

Every hitter in baseball performs a uniquely personal ritual before each pitch. This ritual consists of a series of specific behaviors: stepping away from the plate, adjusting themselves (sometimes in PG rated fashion), glancing toward the third base coach for signs, more often than not they spit – no one spits like big league ball players – then stepping back into the batter’s box, perhaps tapping the plate or their cleats, before going into their stance. They do the same thing, the same way, every single time. While every hitter engages in these behaviors for the same reason – to help them focus – both the specifics of the ritual and the batting stance are highly individualistic; no two hitters do it quite the same.

While I imitated their behavior on the field and developed my own set of batting rituals, I knew very little about my heroes’ personal lives and didn’t really think much about it. I was far more concerned with their batting averages then what they like off the field. Since I didn’t know what they were like as real people, they couldn’t actually teach me much about real life. They were heroes, not role models.

The real role models were the people in my immediate environment: my parents, my older siblings, my teachers at school. They were the ones who taught me how to be responsible, how to conduct myself in public, the proper way to treat other people, how to respond to adverse circumstances, how to give and how to receive. And so much more. While they used words to instruct and correct, observing their behavior was what laid the foundations for my values and attitudes as an adult. The most powerful lessons came from what they did, not what they said.

As a young adult, the notion of hero worship seemed awkward and unnecessary. I had become much too sophisticated and cynical for something so childish. But I still had role models. They came in the form of my coworkers, other caregivers whose behavior I admired based on my own values. My formal training and directives from management instructed me to treat the residents with caring and respect, but they couldn’t tell me how to do it.  It was in watching how other caregivers approached and responded to residents, the real-life interactions with all the give and take within the context of care, that provided the model and showed me how to practice genuine compassion. The lesson was in the act and how it made me feel while I observed it.

Later in life, I rediscovered the concept of heroes. However, instead of the larger than life athletes of my youth, they came in the form of everyday people whose behavior I found inspiring in some way. Like a 9 year-old rider named Nathan who I met when I began taking horseback riding lesson a few years ago. Both Nathan and I were beginners, starting at the same skill level. We didn’t end that way.

Nathan was born with a moderate form of cerebral palsy. However, through treatment, including a long series of surgeries, a lot of physical therapy and tons of family and community support, Nathan was able to ride a horse. Not only did he learn how to ride, but he started performing as an equestrian vaulter.

Equestrian vaulting is a unique sport and performance art that combines elements of dance and gymnastics on a moving horse. The horse moves at either the walk or the canter and is tethered by a lunge line operated by an instructor or coach who thus controls the horse’s movement. This leaves the rider free to focus on his or her performance.

I participated in vaulting too. But I never progressed past the walk. While the movements at the beginning level are relatively simple, the fact that the horse is moving complicated things and I couldn’t master even the basic movements at the canter. But Nathan did.

By the time I discontinued my lessons four years later, Nathan was riding at a couple levels above me. As impressive as that was, what really inspired me was the manner and attitude he brought to the sport. As a performance art, so much of equestrian vaulting is about presentation: doing something that is very difficult and making it look easy. While the movements require technical skill and considerable physical exertion, each one is capped with a moment of showmanship: the graceful wave, the smile, the playing to the audience and judges. In these moments, Nathan excelled. He was a natural, the source of his audience appeal came from within. He absolutely loved being on the horse and performing in front of those people. It wasn’t just his success in overcoming the physical obstacles that I found heroic, it was his courageous and irrepressible desire to experience and express joy in what he was doing.

More recently, my concept of heroes has blended with who I consider role models. It’s just one thing now.  I am inspired by and want to emulate anyone who, like Nathan, refuses to allow difficult circumstances to keep them from finding happiness and meaning in their engagement with the world around them.

The reality is that if you live long enough, you’re going to experience loss and change, sometimes deep loss and drastic change. We all, at any age, can experience a sense of existential dread, that underlying anxiety that the things we rely on to give us our identity can breakdown and be taken from us. For our elders in Long Term Care, that dread often is their reality. I admire and learn from those who have suffered this kind of loss, but are willing not just to continue, but have the courage to redefine what to them makes life worth living. As I enter my seventh decade on this planet, these are my heroes, these are my role models.

As caregivers, we need not be passive bystanders, silent admirers to the courage of our elders. Since we are there, with them, we have an opportunity to play a crucial role in facilitating that courage. It’s not a matter of simply telling them that life is still worth living, but to discover to the best of our ability what that means for them, one person at a time. Because that definition is as unique and individual as the batting rituals of the heroes of my youth. 

Among Kindred Spirits

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Yang

In today’s post, I would like to share my thoughts regarding our participation in the 2016 Pioneer Network Conference.

To begin with, this was the first opportunity that Alice, May, and I got to meet each other in person. What a pleasure. After working with my co-contributors via the Internet for over two years, I knew that they were both talented and creative writers who shared my core values as a caregiver. But in getting to know them in person, I discovered two witty, well-read, and sincere individuals who were just fun to be around. It was easy see how their passion and dedication for their creative work as writers blends so well with the compassion and dedication they have toward their elders. This was evident in our conversations and in our presentation at the conference.

As special treat, we got to meet our sometime contributor and much appreciated supporter, Minstrel. This was a huge surprise, because we had no inkling that she was going to attend the conference. It was great “talking shop” with her and getting to know her a little better. Meeting her was definitely one of the highlights of the conference for us.

The conference was a surreal and wonderful experience for us. We were very well treated, not only in regard to the accommodations, which were first rate, but in the support and encouragement we received from the Pioneer Network Conference staff. Public speaking is not exactly our forte, but we felt like we were in the hands of pros, and their guidance and preparation made us feel as comfortable and confident as possible.

Alice, May, and I were given the honor of speaking to the opening plenary session of the 2016 Pioneer Network Conference. CNA’s have presented in previous conferences, but this was the first time direct care workers have addressed a plenary session. While we were thrilled with the opportunity to share our work and were very well received, it became clear after spending a few days at the conference that our invitation to appear said a lot more about the Network and the direction it is heading than it did about us.

The Pioneer Network is at the center of a culture change movement that recognizes the significance and power of the caregiver-resident relationship. While the movement has always placed this relationship at the heart of culture change, there is a growing sense that caregivers must become more active within the movement itself. Last year, only five percent of the attendees at the conference were CNAs. I’m not sure how many caregivers were there this year, but I expect it’s up from previous years. And I think it’s only the beginning.  

In coming years, I would not be surprised to see increased efforts by conference planners to reach out not only to caregivers, but to any class of workers within Long Term Care who have daily direct contact with residents. Moving away from medical and institutional models, and toward person centered models means that how elders perceive their experience in Long Term Care is paramount.  Central to that experience are the bonds they form not only with caregivers, but with housekeepers, maintenance workers, food service personnel, physical therapy aides, activity therapists – anyone, in fact, in the “neighborhood” who has daily personal direct contact with our elders.

There were times before, after, and even during our presentation that I had a sense of preaching to the converted. Obviously, this was friendly territory for caregivers who share the vision and values of the Network. At the same time, the genius of this movement lies in its acute self-awareness. Those at the center of it understand that the movement must perpetually remake itself based on the actual experience of elders and those closest to them. The movement wants and needs to be challenged, lest it become irrelevant to the people it purports to serve. If culture change means a shift in attitudes and behavior of caregivers toward those for whom they care, it also means the development of a deeper awareness on the part of policy makers – and on the part of advocates for change – of how caregivers actually experience the work. I hope that our effort to enhance such awareness did indeed serve as a challenge to the movement.

Of course, through the sessions and just talking to people, we learned a great deal at the conference ourselves. We hope that at least some of this will be evident in our future blog posts. As this movement evolves, we as individuals will have to grow with it.  New ideas emanating from practitioners at every level ensure a steady supply of new and creative approaches to old problems. Personally, I was humbled by how much I still need to learn.

Perhaps what struck me the most was how quickly we felt at home at the conference. While it was a surreal and wonderful experience, there was also something very familiar about the people there. These were kindred spirits who believe in the same thing we do. It was an honor and a pleasure to be among them.

What it’s all about

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Yang

 

I’m going to post my thoughts regarding our time at the 2016 Pioneer Network Conference in more depth next week. Today, I would like to address an incident that occurred during the conference orientation on Sunday. It was a little unsettling and it affected me in a personal way.

It happened as Barry Barkan of the Live Oak Institute and one of the founders of the Pioneer Network, was closing the orientation with what he described as a “solemn ritual” that went back to the early days of the Network. In a gentle and reverent tone, he instructed the group of a hundred or so orientees to form a circle around the auditorium. As we linked hands in anticipation of a prayer or a pledge or some version of Kumbaya, Barry bowed his head for a moment, then looked up and did this:

Put your right hand in,

Put your right hand out…

Oh, that.

Let’s get something straight:

I don’t do the Hokey Pokey.

I don’t put my whole self in

I don’t put my whole self out

And I certainly do not “turn myself about.”

But I did on Sunday.

Barry Barkan, Miracle Worker, got me, a life-long anti Hokey Pokier, to perform this absurd children’s dance. And I liked it.

It wasn’t the social pressure. A good portion of the group chose not to participate and I could have easily joined the ranks of my brother and sister Hokey Pokey objectors and not have suffered any of the awkwardness of being the lone dissenter.

I did it not just because Barry is an instantly likable person …

I mean look:

Solidarity through Hokey Pokey

Solidarity through Hokey Pokey

I did it, and I liked doing it, because his approach, the buildup and the subsequent surprise (Humor 101), was utterly disarming. It allowed us to drop our social armor and just have a bit of fun.

The moment was made possible by an understanding of how we were perceiving the situation, the use of humor to lighten the mood, and the reliance on an indirect approach. Had Barry taken a direct approach and told us to get in a circle for the Hokey Pokey because it was the designated time for the Relax and Have Fun portion of the orientation, I would have indeed “put my whole self out”… of the room. As soon as I navigated the one-way traffic jam at the door.

This really is “what it’s all about.” A person centered environment means that as we approach and respond to our elders, we pick up on the cues that provide us with an awareness of how they as individuals are perceiving the situation and use this as the context for our interaction with them. An unhurried and indirect approach with a light touch creates an atmosphere of cooperation and reassures our elders that they are in control.

I didn’t have to do the Hokey Pokey. I wanted to. And I would do it again, reserving of course, my right to refuse.

We Still Have a Long Way to go

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Yang

In Being Mortal, Atul Gawande tells us: “A monumental transformation is occurring. In this country and across the globe, people increasingly have an alternative to withering in old age homes and dying in hospitals – and millions of them are seizing the opportunity. We’ve begun rejecting the institutional version of aging and death, but we’ve not yet established our new norm… With this new way, in which we together try to figure out how to face mortality and preserve the fiber of a meaningful life, with its loyalties and individuality, we are plodding novices. We are going through a societal learning curve, one person at a time…”  (Page 193)

Sometimes a little historical perspective can be encouraging. The “societal learning curve” Atul Gawande alludes to is actually part of a larger learning process that has been going on for decades. This rejection of the institutional version of aging and death is simply the latest stage of an ongoing societal response to profound social, medical, and economic changes as they relate to issues of elder care. A brief outline of how we got to this stage might be useful.

Until the mid-20th Century, elder care was primarily a function of the extended family. Those who were unfortunate enough to have no family or who were abandoned by their family, were forced to live out their remaining days in what were known as “almshouses” or “poor houses.” These residential institutions were a kind of catch all, housing the frail, the infirmed, the insane, the developmentally disabled, or people who simply had nowhere else to live. They were universally underfunded, barely staffed, and had little public oversight. The living conditions were deplorable. Horror stories involving starvation, fatal neglect, exploitation, thievery, and outright torture were not uncommon.

With the restructuring of the social welfare system after WWII, the poor house became a thing of the past.  In the 1950’s the federal government established a lending program that enabled entrepreneurs to build for-profit institutions designed specifically for elder care. These institutions were the first of what we would now recognize as the modern nursing home.

The 20th century also brought a significant demographic shift. Due to medical advances, improved sanitation, and infection control and treatment, people were living longer. In 1900, life expectancy in the United States was under 50. By 1960 that shot up to age 73 for women and a little less for men. The trend continues today and within thirty years we will have as many people over eighty as there are under five.

At the same time, social and economic changes resulted in an increasing number of women entering the workforce. By 1960, the percentage of the female population in the labor force had doubled since the turn of the century. This trend would continue through the second half of the 20th Century. Since women traditionally bore the burden of the majority of caregiving duties, families increasingly relied on institutions for the care of the elderly and disabled. In the early part of the 20th Century, 60 percent of those over age 65 resided with a family member. By 1960, that figure dropped to 25 percent. The fledgling nursing home system was being overwhelmed.

To meet the demand, the federal government stepped in with major legislation, the most significant being the establishment of the Medicare and Medicaid programs in the mid-60’s. With this stable source of funding, the number of nursing homes exploded. From 1965 to 1973 the number of beds doubled.

Living conditions varied in these new homes and too often they were substandard.  Medicare and Medicaid specified they would only pay for care in facilities that met basic health and safety standards. However, policy makers knew that a good portion of these facilities could never hope to meet these standards and they feared there wouldn’t be enough homes to meet the demand. The result was a lenient regulatory posture allowing “substantial compliance.” That is, when it came to standards, “close enough” was good enough to keep you open.

During the 70’s and 80’s, the Long Term Care industry came under increasing public scrutiny. Congressional hearings citing conditions such as inadequate nutrition, dehydration, overdrugging, excessive use of physical restraints, failure to provide prescribed therapies and inattention to the psychosocial needs of nursing home residents, resulted in a public outcry for more strict enforcement of Medicare and Medicaid guidelines.  The passage of the Omnibus Budget Reconciliation Act of 1987 (OBRA) established new guidelines for the use of physical and chemical restraints, created a nursing home resident bill of rights, and mandated quality assurance standards, established a standard survey process and mandated training and educational requirements.

While OBRA ’87 resulted in tangible improvements in the life of nursing home residents, a substantial proportion of the nation’s nursing homes were still being cited for inadequate care. In particular, the industry continued to be plagued with staffing problems, especially in direct care. In 2001, CMS reported that more than 90 percent of facilities nationwide did not have sufficient staff to meet the residents’ needs or to prevent avoidable harm. Most caregivers working in LTC today would agree that this problem persists in 2016.

In the last three decades there has been a number of efforts to provide an alternative to traditional institutional elder care. In the 90’s assisted living facilities began to emerge. Originally, these were intended to eliminate the need for nursing homes altogether by offering a smorgasbord of services in a setting that gave residents maximum freedom and autonomy regardless of their physical limitations. However, today the assisted living facility is generally regarded as simply an intermediate stage between independent living and life in a nursing home. Meanwhile, the emergence of programs such as the Eden Alternative, the Green House Project, Hospice Care, PACE, and other community based services are indicative of an ongoing societal effort to redefine elder care.  

In less than seven decades, elder care has transformed from what was primarily a function of the extended family to a responsibility of the social welfare system.  As societal institutions go, seventy years is not that long.  If the 50’s style nursing homes could be considered the infancy of the modern Long Term Care system, then what we are experiencing now could rightly be thought of as its adolescence. If we are still grappling with problems of how to properly approach the issues of aging and elder care, it’s because we’re relatively new at it. And like a confused teenager with that “baby’s brain and old man’s heart,” we are still trying to find our way.

While we have to recognize the progress that has been made in Long Term Care, in terms of transforming the culture of aging and elder care in way that “preserves the fiber of a meaningful life,” we still have a long way to go. In fact, as Dr. Gawande’s “plodding novices,” we’re just getting started. I find that thought encouraging.

The First CNAs: Career Nursing Assistants

NAWeekToday is National Career Nursing Assistants Day. It is the first day of the 39th Annual Nursing Assistants Week, sponsored by the National Network of Career Nursing Assistants.

According to the NNCNA website: “The annual observance of Career Nursing Assistants’ Day and Nursing Assistants’ Week began in Ohio in 1977 as the Ten Year Club, and expanded nationwide by request in 1985. Since that time, this popular nursing assistant recognition program has grown to include thousands of facilities and organizations joining together each year to recognize and honor nursing assistants in long-term care services.”

NNCNA Founder and Director, Genevieve Gipson (“Jeni”) tells us that there was a time when caregivers weren’t even referred to as nursing assistants or nurse’s aides, but simply as “the help.” According to Jeni, caregivers “lacked any kind of training, identity, or recognition” and the organization was established to help provide all three.

In a 1977 meeting of the Nursing Assistants’ Representatives Committee of NE Ohio under Jeni’s direction, the issue of an appropriate title for caregivers was discussed. “As we were struggling to come up with a suitable title for the job, a caregiver interjected: ‘But, Jeni, to me this is not just my job – this is my career.’ And we all thought the word ‘career’ should absolutely be in the title.”

Thus the first CNAs: “Career Nursing Assistants.”

There are those who reject the idea of a “career” nursing assistant. They regard caregiving as nothing but an entry level position, a stepping stone on a career path that leads to positions requiring advanced education and ever greater responsibility, pay and prestige.  It can be that, of course.  Working as a caregiver can provide invaluable experience and insight that can serve those who choose an “upward” career path for their entire lives. It is often said by caregivers that the best RNs worked as CNAs.

But, there are those who do choose direct care work as their career. The Long Term Care system and the residents who are served by LTC benefit a great deal by those who make that choice. In a system beset by chronic high turnover rates of direct care staff and is now threatened by a looming staffing shortage crisis, career caregivers provide continuity of care and the kind of leadership so desperately needed in the trenches of Long Term Care.

Despite their value, career caregivers continue to suffer from low pay, inadequate training, and a lack of real support. Long Term Care needs to do a better job at investing in these remarkable workers.

It is right that we take a day to recognize the value of these deserving workers and honor them for their contributions.

To help celebrate National Career Nursing Assistants Day and Nursing Assistants Week, CNA Edge is offering a free download now through Saturday of our book CNA Edge: Reflections from Year One. The book is a collection of over 80 essays about Long Term Care written from the perspective of CNAs. For Kindle Unlimited Subscribers go to: CNA Edge: Reflections from Year One. Or, to get the book in a PDF via email, please contact us at cnaedge@hotmail.com with “Request Year One” in the subject line.

For more on the National Network of Career Nursing Assistants and NAWeek go to:cna-network.org